xxx red flag for EYE xxx if you have time Flashcards
what are the red flags for eye examination ?
eye pain moderate to severe
photophobia
visual disturbances - sudden and persistent visual loss for more than 60 minutes
red eye
trauma
what causes the red flag for eye pain ?
acute close angled glaucoma
uveitis
aggressive keratitis
what causes the red flag for photophobia ?
corneal diseases - bacterial keratitis
anterior uveitis
what causes the red flag for visual disturbances ?
persistent visual loss that lasts for more than 24 hours
sudden painful loss :
vascularity problem - retinal vein and artery occlusion
temporal arteritis - anterior ischemic optic neuropathy
stroke affecting visual pathway
vitreous hemorrhage
wet age related macular degeneration
retinal detachment
gradual painless loss : cataracts refractive error dry age related macular degeneration open angle glaucoma tumors affecting visual pathway nutritional optic neuropathy
painful loss acute close angles glaucoma optic neuritis temporal arteritis - involves headache rather than eye pain - anterioir ischemic optic neuropathy uveitis keratitis endophthalmitis
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transient visual loss - lasting less than 24 hours
migraine - typically only one hemifield
amaurosis fugal - profound vision loss in one eye caused by vasculitis or vascular disease
papilloedema
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Vision loss due to a functional neurological disorder.
the person has physical symptoms that no medical condition, physical examination or testing can explain.not caused by a physical neurological disease or disorder
is a common presentation, although it should always be a diagnosis of exclusion. It is more common in teenagers and often related to underlying stress and anxiety.
ntermittent blurred vision sometimes with brow ache and photophobia are common, however, complete loss of vision and double vision are also well-recognised presentations.
whenever exploring eye PAIN or any type of PAIN what do you use ?
SOCRATES
site - where is the pain
onset - how did the pain start , suddenly or gradually / what were you doing when the pain started
did the pain wake you from sleep
character of the pain
radiation
associated symptoms - nausea , vomitting ,
time course -
how has the pain changed over time
does pain come and go
exacerbating or relieving factors
severity
on a scale one to ten how severe is the pain 10 being the highest
what is the epidemiology of temporal arteritis / giant cell arteries ?
females more
70 or more peak incidence
what is the aetiology of temporal arteritis/ giant cell arteries ?
genetic predispostion
VIRAL - parvovirus B19
POLYMYALGIA RHEUMATICA - 50 percent of patient with giant cell arteritis have polymyalgia rheumatica
what is the clinical features of giant cell arteritis / temporal arteritis ?
fever , weight loss, night sweats
mainly of SHOULDER and HIP joints - myalgia and arthralgia
arterial inflammation - extrocranial branches of the common carotid , internal carrots and external carotid - temporal artery most affected
-NEW ONSET UNILATERAL/BILATERAL headache
pulse synchronous throbbing
typically located over the temples
- hardened and tender temporal artery
JAW claudication - pain when chewing
VISION LOSS - due to inflammation and occlusion of the ophthalmic artery
= SCINTILLATING SCOTOMA - arch-shaped area of decreased vision that starts centrally and shifts peripherally.
Amaurosis fugax or permanent loss of vision - is a painless temporary loss of vision in one or both eyes. (anterioir ischemic optic neuropathy)
diplopia - due to ischemia of the extraoccular muscle , occulomtor nerves or brain stem
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large vessels giant cell arteritis : INVOLVES THE AORTA AND PRIMARY BRANCHES - angina pectoris acute coronary syndrome limb claudication asymmetrical pulses and BP
what is the epidemiology of polymyalgia rheumatica
females
most common rheumatic disease f elderly onset over 70 years old
northern europe descent
ASSOCITED WITH GIANT CELL ARTERITIS
what are the clinical features of polymyaglia rheumatica ?
fever , weight loss , night sweats
fatigue
musculoskeletal :primarily affects shoulders , neck , pelvic girdle
symmetric pain , worst at night
morning stiffness >45 mins
muscular atrophy not caused by PMR but reduced activity
what is the diagnosis of giant cell arteritis ? and PMR?
inflammatory markers - ESR and CRP high
gold standard - TEMPORAL ARTERY BIOPSY
duplex ultrasound - halo sign
non compressible artery with the ultrasound probe
stenotic and occlusive
suspected cranial and extrocranial involvement - high resolution MRI / CTA / FDG-PET
what is the clinical criteria to difffrentiate GCA from other forms of vasculitis ?
NOT USED TO DIAGNOSE GCA
patient features - new onset headache aged over 50 temporal artery discrepancies - decreased pulsation or tenderness histopathological abnormalities elevated ESR
score 3 or more = GCA likely - investigate
<3 - dd of GCA
some dd of GCA ?
polymyalgia rheumatica
vasculitides
takayasu arteritis
polyarteritis nodosa
monocular vision loss
retinal vein occlusion
what is the treatmnet of GCA ?
NICE guidelines
new visulaloss - assessment of an ophthalmologist whilst waiting - one - off high dose corticosteroids
INITITAE HIGH DOSE INDUCTION GLUCOCORTICOID THERAPY BEFORE DIAGNSTIC WORK UP OF tabIF CLINICAL SUSPICION TO MINIMISE THE RISK OF complication sushi as vision loss and stroke - IMMEDIATE ADMINISTRATION IS IMPORTNAT TO LOWER THE RISK OF PERMANANT VISION LOSS
acute or intermittent visual loss - IV glucocorticoid therapy
or 60-100mg oral prednisolone for 3 days
suspected GCA without visual symptoms- immediately treated with - 40-60mg oral prednisolone
ischemic organ damage - initial pulse therapy with methylprednisolone 0.25-1g /24
response to corticosteroids is usually rapid - if repose to prednisolone is poor - alternative diagnosis
treatment reduced slowly over several months
FOR 2-4 WEEKS
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maintenance - taper glucostricoids
glucocorticoid sparing therapy - who relapse or high risk of complication from long term glucocorticoid
tocilizumab -
methotrexate
what is the complication of temporal arteritis / giant cell arteritis ?
permanent vision loss if left untreated
cerebral ischemia
what is acute close angled glaucoma ?
sudden sharp increase in intraoccqular pressure due to obstruction commonly in the iridocorneal angle
what is the etiology of acute and chronic close angled glaucoma ?
acute
caused by eye injury - adherence of the iris to the trabecular mesh work
mydriasis - drug induced - - anti cholinergic - atropine
darkness - at night pupil dilate
stress or fear
chronic -
anatomic features - shallow anterioir chamber
age high
asian or inuit ethnicity
what are the clinical symptoms of acute angle closure glaucoma
and chronic
sudden onset
unilateral inflamed , red , severely painful eye on palpation
frontal headache
blurred vision , HALOS SEEN AROUND LIGHT
mid dilated , irregular , unresponsive pupil
cloudy cornea
EMERGENCY!!!!! - can cause permanent vision loss
chronic
asymptomatic
progressive vision loss
Caused by acute inflammatory conditions of the iris or prolonged apposition between the structures (e.g., uveitis - peripheral anterioir synechiae
what is the diagnosis of acute angle closure glaucoma ?
acute - emergencyy opthalmic evaluation
confirmed on TONOMETRY elevated intraocular pressure
GONIOSCOPY (GOLD STANDARD) or slit lamp - narrowing or closure of iridocorneal angle
glaucomatous damage performed in all patients- optic disc change - direct fundoscopy
visual acuity
visual field testing
DO NOT USE MUYDRIATIC DRUGS - ATROPINE EPINEPHRINE
and NO DARKNESS FOR EYE TEST - INCREASING MYDRIASIS
IF DIAGNOSTIC FINDINGS ARE inconclusive for angle closure glaucoma what are the DD ?
painful red eye - uveitis
headache with ocular pain - migraine
what is the management of acute closure glaucoma ?
EMERGENCY OPTHALMOLGY CONSULTATION
place patient in supine position - moves len slightly posterioir - opens up the iridiocorneal angle
analgesics
IOP decreasing medication
eyedrops direct parasympathomemtic drug - PILOCARPINE 2 PERCENT
pilocarpine may be ineffective because of iris ischemia. It should still be administered, however, because once the IOP decreases as a result of other agents, the iris becomes responsive to pilocarpine
/ ALPHA 2 AGONIST - apraclonidine
/ timolol - beta blocker (avoid in copd , asthmatic , decompensated heart failure , AV block
PLUS
systemic carbonic anhydrase inhibitor (avoided in pregnancy)
ACETZOLOMIDE (avoid in renal insufficiency) 125–250 mg PO every 6 hours
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vision threatening IOP refectory to medical therapy - anterioir chamber paracentesis
however patient will later on require laser peripheral iridotomy
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Standard of care for acute angle-closure glaucoma as soon as the acute attack is resolved and the cornea becomes clear = Laser peripheral iridotomy
Laser peripheral iridoplasty (gonioplasty)
Indication: persistently elevated IOP despite a patent LPI
Surgical peripheral iridectomy
Indication: an alternative to LP iridectomy in patients with acute/chronic angle-closure glaucoma with pupillary block
what is the complication of acute angle clusire glaucoma ?
rapid permanent vision loss - ischemia and atrophy of optic nerve
what is the treatmnet for chronic primary angle closure glaucoma ?
laser peripheral iridotomy or open surgery iridectomy prevent progression of glaucomatous optic neuropathy
maintenance pharmacotherapy if elevated top despite iridotomy
